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Case Law Database

Access over workers' compensation decisions, including En Banc, Significant Panel Decisions, and writ-denied cases.

Case No. ADJ7049850 ADJ7289794 ADJ7523255
Regular
May 11, 2015

FREDDIE B. GUZMAN vs. MARTENS CHEVROLET, EMPLOYERS COMPENSATION INSURANCE COMPANY

This case involves an applicant seeking reconsideration of an order denying his petition to enforce an award for out-of-pocket medical and travel expenses. The Workers' Compensation Appeals Board granted the petition for reconsideration, finding the applicant was denied due process. The Board rescinded the prior order and returned the matter for further proceedings and a new decision, noting the applicant's right to a hearing was violated. This decision allows for a proper hearing to address the disputed reimbursement claims.

Workers' Compensation Appeals BoardPetition for ReconsiderationPetition to Enforce AwardSelf-Procured TreatmentOut-of-Pocket ExpensesDue ProcessWCJ OrderHearing DenialMedical Expenses ReimbursementTravel Expenses Reimbursement
References
Case No. ADJ1868495 (VNO 0452398) ADJ4538828 (VNO 0468076)
Regular
Dec 14, 2012

JORGE HERNANDEZ vs. CRESCENT TRUCK LINES, INC., CALIFORNIA INSURANCE GUARANTEE ASSOCIATION, SEDGWICK CLAIMS MANAGEMENT SERVICES, RELIANCE NATIONAL INSURANCE COMPANY

This case concerns the California Insurance Guarantee Association (CIGA) seeking reimbursement from the State Compensation Insurance Fund (SCIF) for costs incurred administering workers' compensation claims. The WCJ initially awarded CIGA reimbursement for benefits paid but not for associated administration expenses. The Appeals Board granted CIGA's reconsideration petition, ruling that CIGA is entitled to reimbursement for both benefits and specific claim administration expenses, including medical-legal costs. The Board amended the findings and award to reflect this, returning the matter to the trial level for further proceedings.

CIGAReliance National Insurance CompanySedgwick Claims Management ServicesState Compensation Insurance Fund (SCIF)Petition for ReconsiderationJoint Findings and Award (F&A)reimbursementassociated expensesmedical treatmentloss adjustment expense
References
Case No. SFO 0438557 SFO 0438562
Regular
May 05, 2008

LISA BURKE vs. WINTERLAND PRODUCTIONS, HARTFORD INDEMNITY & ACCIDENT COMPANY

The Workers' Compensation Appeals Board granted reconsideration to address whether reimbursed expenses should be included in calculating an applicant's temporary disability indemnity rate. The Board reversed the prior award, ruling that reimbursed expenses for meals, lodging, and fuel are special expenses, not remuneration, and therefore should not be included in calculating the applicant's average weekly wage. The decision clarifies that such reimbursements do not constitute "advantages received by the injured employee as part of his remuneration" under Labor Code section 4454.

Workers' Compensation Appeals BoardTemporary Disability IndemnityReimbursed ExpensesEarnings CalculationLabor Code Section 4454RemunerationSpecial ExpensesAverage Weekly WageCumulative TraumaConcert Tour Salesperson
References
Case No. ADJ1643143 (SRO 0122410)
Regular
May 25, 2010

JUAN ESCUTIA vs. NICK LERAS WATER TRUCKS, et al.

The Workers' Compensation Appeals Board affirmed a prior decision holding the State Compensation Insurance Fund (SCIF) liable for reimbursement to the California Insurance Guarantee Association (CIGA). CIGA, adjusting claims for an insolvent insurer, sought reimbursement for various administrative expenses, including bill review, court reporter fees, and opposing counsel fees incurred while administering an injured worker's claim. The Board found these costs, particularly bill review expenses, were part of "incurred losses" under the California Workers' Compensation Uniform Statistical Reporting Plan and thus reimbursable. This decision establishes that CIGA can recover such administrative costs from a solvent insurer when adjusting claims for an insolvent carrier.

CIGASCIFBill ReviewIncurred LossesLoss Adjustment ExpensesInsurance Code Section 1063.1(c)(9)Labor Code Section 5500.5(e)California Workers' Compensation Uniform Statistical Reporting PlanReconsiderationFindings and Orders
References
Case No. ADJ128210 (SAL 0093437) ADJ593542 (SAL 0093436)
Regular
Apr 12, 2010

JORGE RAMIREZ vs. LINO FINATTI, JR., CIGA on behalf of RELIANCE INSURANCE COMPANY, in liquidation, administered by INTERCARE SERVICES, CLARENDON INSURANCE COMPANY, adjusted by NORTH AMERICAN RISK SERVICES

This case involves a dispute over reimbursement for workers' compensation expenses between the California Insurance Guarantee Association (CIGA) and Clarendon Insurance Company. CIGA, covering for Reliance Insurance Company in liquidation, sought reimbursement for administrative expenses in addition to indemnity and medical costs. The arbitrator initially denied administrative expenses due to insufficient justification, but the Appeals Board granted reconsideration. The Board applied the *Ramos* decision, allowing CIGA to recover administrative costs like bill review and utilization review from Clarendon for the applicant's low back injuries.

CIGAReliance Insurance CompanyClarendon Insurance Companyadministrative expensesreimbursementbill reviewmedical managementutilization reviewsubpoenaing recordsjoint and several liability
References
Case No. ADJ579423 (SAL 0092182)
Regular
Oct 27, 2008

DAVID RESENDIZ vs. FRESH WEST HARVESTING, FRONTIER INSURANCE COMPANY, IN REHABILITATION

The Workers' Compensation Appeals Board granted reconsideration, rescinded a prior award, and remanded the case to clarify the evidentiary record. The applicant sought reimbursement for treatment and transportation costs, but the Board found discrepancies between the August 12, 2008 award and a previous March 18, 2008 award. The matter was returned for further proceedings to determine the correct amounts and clarify which expenses were governed by the prior decision.

Workers' Compensation Appeals BoardPetition for ReconsiderationFindings and AwardIndustrial InjuryMedical TreatmentReimbursementSelf-Procured ExpensesMedical MileageTransportation ExpensesPrimary Treating Physician
References
Case No. ADJ3727929
Regular
Jul 17, 2013

JOE GAGNE vs. FRU CON CONSTRUCTION, ZURICH NORTH AMERICA

The Workers' Compensation Appeals Board denied the applicant's Petition for Reconsideration. The Board adopted the WCJ's report, which found that the applicant was only temporarily disabled from June 1, 2007, to July 23, 2007, and was not entitled to further travel expense reimbursement. The WCJ determined that while one physician's opinion could constitute substantial evidence, that opinion lacked sufficient clarity and consistency to support the applicant's broader claims of temporary disability and cumulative trauma to the left knee and back. The Board affirmed that a single physician's considered opinion can be substantial evidence, even if inconsistent with other medical opinions.

Petition for ReconsiderationDeniedSubstantial EvidencePlace v. Workmen's Comp. Appeals Bd.Fru Con ConstructionZurich North AmericaADJ3727929SAC 0315536ApplicantTemporarily Disabled
References
Case No. ADJ4157637
Regular
Mar 18, 2010

BEATRICE WEISS vs. TECHNOLOGY FUNDING, LUMBERMEN'S MUTUAL CASUALTY COMPANY, BROADSPIRE, a CRAWFORD COMPANY

This case involves an applicant who sustained a spinal injury in 2000 and was awarded permanent total disability and ongoing medical treatment, including assisted living. The Workers' Compensation Appeals Board (WCAB) clarified that the applicant is entitled to full reimbursement for assisted living costs incurred after exhausting long-term care insurance, as medical treatment for industrial injuries is not apportionable, even if concurrent non-industrial conditions exist. However, the WCAB reversed an award for personal duty aides, finding insufficient evidence of their necessity due to the industrial injury, and denied claims for interest on unpaid bills and guardianship costs. The WCAB affirmed reimbursement for dental expenses necessitated by medication for the industrial injury, while excluding attorney fees for enforcing treatment denials.

Workers' Compensation Appeals BoardBeatrice WeissTechnology FundingLumbermen's Mutual Casualty CompanyBroadspireCrawford CompanyADJ4157637SFO 0445495Opinion and Decision After Reconsiderationpermanent total disability
References
Case No. ADJ4659072 (FRE 0250287)
Regular
May 23, 2018

JIM WILLIAMS vs. INTERSTATE DISTRIBUTING, INC., ZURICH AMERICAN INSURANCE CO., ZURICH NORTH AMERICA

This case involves a defendant's petition for reconsideration of an administrative law judge's (WCJ) order awarding penalties for delayed permanent disability benefits and out-of-pocket expense reimbursement, along with attorney's fees. The Workers' Compensation Appeals Board (WCAB) granted reconsideration. The WCAB affirmed the penalty for delayed permanent disability payments, finding that the off-calendar orders did not resolve penalties accrued after the initial award. However, the WCAB amended the order to defer the issue of out-of-pocket expense reimbursement penalties, returning the matter to the WCJ for further proceedings on that specific issue.

Workers' Compensation Appeals BoardPetition for ReconsiderationFindings of FactAdministrative Law JudgePenaltyPermanent Disability BenefitsOut-of-pocket ExpensesLabor Code Section 5814Labor Code Section 5814.5Mandatory Settlement Conference
References
Case No. ADJ6774605
Regular
Sep 02, 2016

Tammy Tran vs. PROFESSIONAL SERVICE INDUSTRY, ZURICH LOS ANGELES

The Workers' Compensation Appeals Board granted reconsideration of the Administrative Law Judge's (ALJ) decision, which limited reimbursement for self-procured medical treatment. The Board found that the ALJ erred by only allowing reimbursement for treatment from the claim date until the denial date. Citing *McCoy v. Industrial Accident Commission*, the Board determined that the employer is liable for all reasonably necessary self-procured medical expenses incurred after the employer denied the claim, as this denial effectively refused to provide treatment. Consequently, the Board rescinded the ALJ's award and remanded the case for further proceedings to determine the reasonableness of all self-procured medical expenses.

Workers' Compensation Appeals BoardPetition for ReconsiderationFindings and AwardSelf-Procured Medical TreatmentLabor Code Section 4600McCoy v. Industrial Accident CommissionDenial of ClaimReimbursementIndustrial InjuryReasonably Necessary Treatment
References
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